Republic of the Philippines

Department of Health
SAN LAZARO HOSPITAL
Manila, Philippines

Date:__________

Patients Name: _______________________ Age: ____________

Hospital No.: _________________________ Gender: _________
Rx

M. D. ________________
Lic. No. ______________
S2 Lic. No. ____________
“Observe Generic Law”
Ward: _______ Classification:__________
FM-MS-PD-011
Date Effective: January 21, 2019, Rev. 0